Jay Joseph, Psy.D.
LICENSED PSYCHOLOGIST, # PSY 18905
5665 College Ave, Suite 220C, Oakland, CA 94618
MAILING ADDRESS: p.o. bOX 5653, bERKELEY, ca94705-5653
tEL.: (510) 295-5490. E-MAIL:
CONSENT FOR TREATMENT AND CONFIDENTIALITY
I agree to participate in psychotherapy with Dr. Jay Joseph of my own free will. I understand that all information I disclose in therapy sessions is strictly confidential. However, I also understand that under certain circumstances disclosure is mandated or permitted by law. For instance, when there is reasonable suspicion of physical and/or sexual abuse of children or the elderly, and when a client is likely or intends to harm himself or herself (suicide) or others (homicide).
I agree to attend counseling sessions regularly. If I cannot keep my appointment, I agree to call at least 24 hours in advance to cancel. If I do not cancel or reschedule at least 24 hours in advance of my session, I understand that I may be charged the full fee for the session.
MY SIGNATURE INDICATES THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS
Client (Parent or Guardian)Date
Witness (Therapist) Date
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INTAKE FORM
Name ______Date ______
Street Address ______
City ______State ______Zip Code ______
Mailing address (if different from above)______
Telephone: Home ______Work ______
Cell ______
E-mail address ______
Insurance plan (if applicable)______
Insurance ID# ______Insur Group# ______
Male ____ Female ____ Date of Birth ______Age ______
Highest level of education ______Referred by ______
Occupation ______
(For children) Name of school and grade level ______
Relationship status ______Years in current relationship ______
Spouse/partner name ______Age ____ Occupation ______
Children (names, ages) ______
Siblings (names, ages) ______
Parents or step-parents (Ages or year of death) ______
______
Disabilities ______
***
Person to call in emergency (1) ______Phone ______
Person to call in emergency (2) ______Phone ______
Reason you decided to enter therapy______
______
Medical doctor ______Phone ______
Medical doctor ______Phone ______
Current medications______
Past medications ______
Past and present medical care (specify major problems, accidents, hospitalizations)
______
______
______
Past and present counseling or psychotherapy:
Check here if none ______
1. Psychotherapist name ______Dates: ______to ______
Reason for seeking therapy ______
Outcome______
2. Psychotherapist name ______Dates: ______to ______
Reason for seeking therapy ______
Outcome ______
Have you ever been hospitalized for psychiatric reasons? ______
If yes, please describe, including dates ______
______
Past or present drug or alcohol use? ______
______
Do you have a family history of alcoholism, psychological problems, violence, or suicide?
______
Have you experienced traumatic events in your life? If so, please describe and give approximate dates______
______
Current living situation ______
What causes you stress? ______
______
How would you describe your social support network? ______
______
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